Medicina familiar, principios bioéticos y final de la vida en Colombia / Family Medicine, Bioethical Principles and End of Life in Colombia

Introducción: La medicina familiar, dentro de su enfoque biopsicosocial, acoge la valoración integral de cada individuo en su curso de vida, donde es indispensable integrar todos los principios bioéticos para brindar una atención adecuada, oportuna y humanizada. El abordaje del especialista en medicina familiar sobre el final de vida debe estar ligado a estos aspectos, lo que permite ampliar la relación clínica desde el paciente hasta su núcleo familiar y su equipo en salud. Objetivo: Discutir los principios bioéticos desde una perspectiva integrativa a partir de un recorrido por los principales apartados legales que se han desarrollado en Colombia desde la sentencia C-239 de 1997, en relación con el derecho a morir dignamente. Métodos: Se realizó una revisión narrativa mediante la búsqueda en PubMed, Elsevier, Scielo y la normativa del contexto colombiano. Conclusiones: La disponibilidad de la información permite tener claridad sobre los conceptos al final de vida y el quehacer de los profesionales de la salud en esta etapa, que permita brindar al paciente y a su familia información clara y alternativas en su manejo integral, que dignifique la relación médico-paciente-familia-equipo de salud(AU)

Introduction: Family medicine, within its biopsychosocial approach, welcomes the comprehensive assessment of each individual in his or her life course, where it is essential to integrate all bioethical principles to provide adequate, timely and humanized care. The approach of the family medicine specialist at the end of life should be linked to these aspects, which allows extending the clinical relationship of the patient to the family nucleus and the health team. Objective: To discuss bioethical principles from an integrative perspective based on the review of the main legal paragraphs that have been developed in Colombia since the C-239 ruling of 1997 in relation to the right to die with dignity. Methods: A narrative review was carried out through searches in PubMed, Elsevier, SciELO and in the normativity of the Colombian context. Conclusions: The availability of information allows clarity about the concepts at the end of life and the work of health professionals at this stage, which allows providing the patient and family with clear information and alternatives in their comprehensive management, which dignifies the doctor-patient-family-health team relationship(AU)

Abordagem do paciente terminal: aspectos psicodinâmicos - "A morte como símbolo de transformação" / Approach to terminally ill patients: Psychodynamic aspects - "Death as a symbol of transformation" / Abordaje del paciente terminal: aspectos psicodinámicos - "La muerte como símbolo de transformación"

O autor discute a importância de se resgatar a morte como algo natural, tirando-a do interdito em que se encontra. Tenta mostrar o quanto este aspecto cria distorções para a vida, determinando uma série de distúrbios na conduta médica, em especial na abordagem do paciente terminal. Defende a ideia de que é uma doença da nossa cultura ocidental e a situação que leva a esta repressão é negação da morte. Dentro das referências teóricas da Psicologia Analítica de Jung, o autor propõe condutas para se tentar resgatar a vivência simbólica da morte restituindo-se a polaridade dialética Vida-Morte. Defende a proposição de que a vida só pode ter um sentido pleno se não negarmos a morte. Propõe que, como no parto, o progresso da Medicina se harmonize com respeito aos limites da Vida e da personalidade do paciente, frequentemente desrespeitados. Discute a morte como símbolo fundamental dentro do processo de individuação.

The author discusses the importance of readdressing death as something natural, retrieving it from the interdict in which it finds itself. He attempts to show the extent to which this aspect creates distortions to life, determining a series of disorders in medical conduct, especially in the approach to terminally ill patients. He defends the idea that it is a disease of our Western culture and that the situation that leads to this repression is the negation of death. In line with the theoretical references of Jung's Analytical Psychology, the author proposes conducts to try to rescue the symbolic experience of death and restore the life-death dialectical polarity. He supports the proposition that life can only have a full meaning if we do not negate death. He proposes that, as in childbirth, the progress of medicine should harmonize with respect to the limits of life and the patient's personality, which are often disrespected. He discusses death as a fundamental symbol within the individuation process.

El autor discute la importancia de rescatar la muerte como algo natural, sacándola del entredicho en que se encuentra. Intenta mostrar cuánto este aspecto crea distorsiones para la vida, determinando una serie de perturbaciones en la conducta médica, especialmente en el abordaje del paciente terminal. Defiende la idea de que es una enfermedad de nuestra cultura occidental y la situación que lleva a esta represión es la negación de la muerte. Dentro de los referentes teóricos de la Psicología Analítica de Jung, el autor propone conductas para tratar de rescatar la experiencia simbólica de la muerte, restituyendo la polaridad dialéctica Vida-Muerte. Defiende la proposición de que la vida sólo puede tener pleno sentido si no negamos la muerte. Propone que, como en el parto, el progreso de la Medicina debe armonizar respecto a los límites de la Vida y de la personalidad del paciente, que muchas veces son irrespetados. Se habla de la muerte como símbolo fundamental dentro del proceso de individuación.

Condutas éticas e o cuidado ao paciente terminal / Ethical conduct and terminal care / Conductas éticas y el cuidado al paciente terminal

Resumo Dadas suas peculiaridades, a terminalidade destaca a necessidade de individualização do plano terapêutico e integralidade da assistência no cuidado em saúde. Este artigo analisou 23 publicações científicas com temática relativa a terminalidade e cuidados paliativos e discorreu sobre a abordagem terapêutica do paciente em terminalidade e a incorporação de diferentes práticas integrais em saúde. Buscou-se evidenciar que o reconhecimento das características da terminalidade possibilita estabelecer adequado estudo de prognóstico e implementar plano de cuidados que supra as necessidades do paciente terminal, com assistência pautada em princípios bioéticos, respeitando a vontade e particularidades do indivíduo. Conclui-se que os cuidados paliativos constituem importante instrumento no manejo de angústias biopsicossociais e espirituais de pessoas em terminalidade, por possibilitarem assistência ampliada do cuidado, promovendo dignidade, minimização do sofrimento e melhora na qualidade de vida desses pacientes e de seus familiares.

Abstract Given its peculiarities, terminality highlights the need for an individualization of the therapeutic plan and integrality of assistance in health care. This article analyzed 23 scientific publications with thematics related to terminality and palliative care and discussed the therapeutic approach to the terminally ill patient and the incorporation of different integral practices in health. We sought to evidence that recognizing the characteristics of terminality makes it possible to establish the adequate prognostic study and implement a plan of care that supplies the necessities of the terminally ill patient, with care based of bioethical principles, respecting the will and particularities of the individual. We conclude that the palliative care constitutes an important instrument in managing biopsychosocial and spiritual angst of terminally ill people, by making ample assistance in care possible, promoting dignity, minimizing suffering, and bettering the quality of life of these patients and their families.

Resumen Dadas sus peculiaridades, el final de la vida señala una necesidad de individualización del plan terapéutico y asistencia integral en el cuidado sanitario. Este artículo analizó 23 publicaciones científicas respecto al final de la vida y los cuidados paliativos y discutió el enfoque terapéutico del paciente terminal y la incorporación de diferentes prácticas integrales de salud. Se buscó demostrar que el reconocimiento de las características del final de la vida establece un adecuado pronóstico y puesta en marcha de un plan de cuidados que abarque las necesidades del paciente terminal, con asistencia basada en principios bioéticos, respetando la voluntad y particularidades del individuo. Los cuidados paliativos resultan ser un instrumento importante al manejo de las angustias biopsicosociales y espirituales de las personas en situación terminal, pues permiten un mayor cuidado, promoviendo la dignidad, mitigación del sufrimiento y una mejora de la calidad de vida de estos pacientes y sus familias.

A comunicação de más notícias em Unidade de Terapia Intensiva: um estudo qualitativo com médicos experientes e novatos / Communicating bad news in the Intensive Care Unit: a qualitative study with experienced and novice physicians / La communication des mauvaises nouvelles dans l'unité de soins intensifs: Une étude qualitative auprès de médecins expérimentés et novices / La comunicación de malas noticias en la Unidad de Cuidados Intensivos: un estudio cualitativo con médicos experimentados y novatos

Resumo A Unidade de Terapia Intensiva (UTI) se caracteriza pela alta complexidade, monitoramento contínuo e ininterrupto, destinando-se ao atendimento de pacientes críticos. Comunicar más notícias neste ambiente gera sentimentos intensos para o paciente e seus familiares. O objetivo deste estudo foi compreender como os médicos percebem o processo de comunicação de más notícias na UTI, bem como identificar os fatores que facilitam e dificultam este processo, e os sentimentos gerados no profissional. Os 15 médicos participantes responderam um questionário online com perguntas abertas e fechadas. O processo de comunicação de más notícias foi considerado difícil e emotivo, independentemente do tempo de atuação em UTI. O conhecimento sobre a história do paciente e de seus familiares foi um fator facilitador e as mudanças inesperadas no quadro clínico do paciente foram fatores dificultadores do processo de comunicação. Os médicos reconheceram a necessidade de desenvolver competências para aprimorar a relação com paciente e famílias.

Abstract Characterized by highly complex, continuous and uninterrupted monitoring, the Intensive Care Unit (ICU) focuses on providing care for critically ill patients. Communicating bad news in this environment generates intense feelings for patients and families. Thus, this study sought to understand how experienced and novice physicians perceive the process of communicating bad news in the ICU, as well as to identify the factors that facilitate and hinder this process, and the feelings generated in the professional. A total of 15 physicians answered an online questionnaire with open and closed questions. Participants reported that the process of communicating bad news is difficult and emotional regardless of ICU length of stay. Knowledge about the patients' history and their families emerged as a facilitating factor, whereas unexpected changes in the patient's clinical condition hindered the communication process. Physicians recognized the need to develop skills as to improve physician-patient relations.

Résumé Caractérisée par une surveillance hautement complexe, continue et ininterrompue, l'unité de soins intensifs (USI) se concentre sur la prise en charge des patients gravement malades. Communiquer de mauvaises nouvelles dans cet environnement génère des sentiments intenses pour les patients et les familles. Cette étude a donc cherché à comprendre comment les médecins expérimentés et novices perçoivent le processus de communication des mauvaises nouvelles dans l'USI, ainsi qu'à identifier les facteurs qui facilitent et entravent ce processus, et les sentiments générés chez le professionnel. Au total, 15 médecins ont répondu à un questionnaire en ligne comportant des questions ouvertes et fermées. Les participants ont indiqué que le processus de communication de mauvaises nouvelles est difficile et émotionnel, quelle que soit la durée du séjour à l'USI. La connaissance de l'histoire des patients et de leur famille est apparue comme un facteur facilitant, tandis que les changements inattendus dans l'état clinique du patient entravaient le processus de communication. Les médecins ont reconnu la nécessité de développer des compétences afin d'améliorer les relations médecin-patient.

Resumen La Unidad de Cuidados Intensivos (UCI) se caracteriza por tener un monitoreo continuo e ininterrumpido de alta complejidad, destinado a la atención de pacientes críticos. Comunicar malas noticias en este ambiente genera sentimientos intensos para el paciente y sus familiares. El objetivo de este estudio fue comprender cómo los médicos perciben el proceso de comunicación de malas noticias en la UCI, así como identificar los factores que facilitan y dificultan ese proceso, y los sentimientos generados en el profesional. Los 15 médicos participantes respondieron un cuestionario en línea con preguntas abiertas y cerradas. El proceso de comunicar malas noticias se consideró difícil y emotivo, independiente del tiempo de estadía en la UCI. El conocimiento sobre la historia del paciente y sus familiares fue un factor facilitador, y los cambios inesperados en la condición clínica del paciente fueron los factores que dificultaron el proceso de comunicación. Los médicos reconocieron la necesidad de desarrollar habilidades para mejorar la relación con los pacientes y las familias.

Overview of Perinatal Palliative Care in Brazil

Abstract Significant attention to palliative care in terminally ill patients has only been effective in Brazil since the year 2000, although there have been isolated actions since the 1980s. When the case involves fetuses or neonates unable to cure, communication and care with the family members only received attention and effective organization starting in 2017. Notably in the years 2015 and 2016 there was an epidemic of microcephaly and along with the persistent crisis of drug users has raised the indices of malformations to a level higher than 3 % of the world average. Here we aim the evaluation of: a) social, educational and spiritual profile of the mothers; b) structure of the specific teams related to palliative care in neonatology; c) recommendations and protocols currently used in the country. The method used is an electronic retrospective on databases and government data; evaluation of the location and composition of palliative care teams in the country. The data found clearly point out that for Brazilian women, the characteristics of regionality in the country, educational level, religiousness and quality of life directly influence pregnancy and the acceptance or not of the possibility of death, directly influencing perinatal palliative care, which, by the way, is still developing methodologies for this type of action.

Inpatient Care Expenditure of Terminally Ill Patients in the Geriatric Ward of Peking Union Medical College Hospital / 中国医学科学院学报

Objective To describe the inpatient care expenditure of the terminally ill patients in the geriatric ward of Peking Union Medical College Hospital and facilitate future research on the economic outcomes of hospice and palliative care.Methods The histories of patients admitted to the Department of Geriatrics of Peking Union Medical College Hospital during 2018 were reviewed by trained doctors.According to the diagnosis and overall health state,terminally ill patients were selected and enrolled in the study.Demographics,health and disease information,prescriptions,and expenditure details were retrieved from the HIS system.Results In 2018,35 patients were terminally ill and eligible for hospice care,including 20 males and 15 females,with the average age of(78±8)years(59-91 years),the average age-adjusted Charlson Comorbidity Index of 10±3,and the median Barthel index of 40(10,70).These patients had malignant tumor(23 cases),heart failure(4 cases),end-stage renal disease(1 case),end-stage liver disease(2 cases),dementia(4 cases)and other severe diseases(3 cases).The patients received standard care within the scope of internal medicine and geriatrics.Finally,8 patients died during hospitalization,and 27 were discharged alive.The 35 patients had the median length of stay of 15(12,23)days,the median inpatient expenditure of CNY 21 500(13 800,37 600),and the median daily expenditure of CNY 1425(970,2503).The percentage of expenditure was(28.5±12.3)% for medication,(33.2±18.0)% for tests and examinations,and 11.5%(6.4%,15.8%)for accommodation and medical services.The medications for symptom control costed CNY(77±58)per day on average,accounting for(5.2±3.5)% of the total expenditure.Conclusions The inpatient expenditure for terminally ill patients in the tertiary grade A hospital was higher than that reported in community hospitals providing hospice care.In terms of expenditure constitution,the money spent on medications and tests/examinations were similar,and the percentage of expenditure on medications for symptom control was low.There is a need for further research on the economic impact of hospice and palliative care among terminally ill patients in China.

Terminalidade em UTI: dimensões emocionais e éticas do cuidado do médico intensivista / Terminality in the icu: the emotional and ethical dimensions of the medical care of the intensivist / Terminalidad en uci: las dimensiones emocionales y éticas del cuidado del médico intensivista

Este artigo se propõe a discutir as dimensões emocionais e éticas envolvidas no cuidado do médico com o paciente em situação de terminalidade em UTI. Realizou-se uma pesquisa qualitativa, na qual foram entrevistados seis membros da equipe médica intensivista de um hospital privado de médio porte. Da análise do conteúdo das entrevistas, emergiram seis categorias temáticas: percepção sobre o paciente em situação de terminalidade; emoções frente à morte e ao morrer; conflitos éticos; família diante da terminalidade; comunicando más notícias e relação médico-família no processo de tomada de decisões. Neste trabalho, são apresentadas as três primeiras categorias. Os resultados apontaram que a morte e o morrer são fenômenos que causam estranheza ao médico intensivista, pois este espera conseguir salvar a vida do paciente e conta com equipamentos de suporte avançado de vida. A complexidade envolvida na definição da terminalidade, aliada ao avanço das técnicas da medicina como ventilação mecânica, hemodiálise, nutrição enteral e parenteral, entre outras, podem favorecer a promoção da distanásia em UTI, constituindo um cenário propício para o surgimento de conflitos entre a família e a equipe médica.

The purpose of this article is to discuss the emotional and ethical dimensions involved in the medical care for terminally ill patients held in Intensive Care Unit (ICU). We conducted a qualitative research in which we interviewed six members of the intensivist medical staff of a medium-sized private hospital. Six theme categories emerged from the content analysis: perception of the patient in terminal condition; emotions towards death and dying; ethical conflicts; family facing terminality; communicating bad news; and the doctor-family relation in the decision making process. In this study we will present the first three categories. The results showed that death and dying are phenomena that cause uneasiness in the intensivist doctor, since he/she expects to save the life of the patient and counts with the help of advanced life support equipment. The complexity involved in the definition of terminality, combined with advances in medical techniques - such as mechanical ventilation, hemodialysis, enteral or parenteral nutrition, among others - may favor the promotion of dysthanasia in ICU, establishing a suitable scenario for the emergence of conflicts between the family and medical staff.

Este artículo se propone a discutir las dimensiones emocionales y éticas involucradas en el cuidado del médico con el paciente en situación terminal en UCI. Se realizó una encuesta cualitativa en la cual se entrevistaron a seis miembros del equipo médico intensivista de un hospital privado de porte mediano. Del análisis del contenido de las entrevistas emergieron seis categorías temáticas: percepción sobre el paciente en situación terminal; emociones ante la muerte y al morir; conflictos éticos; familia ante la terminalidad; comunicando malas noticias; y la relación médico-familia en el proceso de toma de decisiones. En este estudio, se presentarán las tres primeras categorías. Los resultados apuntaron que la muerte y el morir son fenómenos que causan extrañeza al médico intensivista, pues éste espera lograr salvar la vida del paciente, y cuenta con equipamientos de soporte avanzado de vida. La complexidad involucrada en la definición de la terminalidad, aliada al avanzo de las técnicas de la medicina, como ventilación mecánica, hemodiálisis, nutrición enteral y parenteral, entre otras, pueden favorecer la promoción de la distanasia en UCI, constituyendo un escenario propicio para el surgimiento de conflictos entre la familia y el equipo médico.

Nurses versus physicians' knowledge, attitude, and performance on care for the family members of dying patients / 한국의학교육

PURPOSE: Nurses and physicians must be competent enough to provide care for the clients. As a lack of knowledge and a poor attitude result in a low performance of delivering care, this study aimed to explore the nurses versus physicians' knowledge, attitude, and performance on care for the family members of dying patients (FMDPs). METHODS: This descriptive study was conducted at the educational hospitals in Isfahan, Iran. The samples were 110 nurses and 110 physicians. The data were collected through a convenience sampling method and using a valid and reliable questionnaire. RESULTS: The average knowledge, attitude, and performance on care for the FMDPs were not significantly different between nurses and physicians (p>0.05). The majority of nurses (55.4%) and physician (63.6%) were at a moderate and a fair level of knowledge of care for the FMDPs. Most of the nurses (81%) and physicians (87.3%) had a positive attitude towards caring the FMDPs. Most of the nurses (70%) and physicians (86.3%) had a moderate and fair performance. CONCLUSION: Having enough knowledge and skills, and a positive attitude are necessary for caring the FMDPs. Nurses' and physicians' competencies must be improved through continuing educational programs and holding international and national conferences with a focus on the palliative care.

Concepções da equipe multiprofissional sobre a implementação dos cuidados paliativos na unidade de terapia intensiva / Perceptions of the multi-professional team on the implementation of palliative care in intensive care units

Este estudo objetivou analisar as concepções da equipe multiprofissional sobre a implementação de cuidados paliativos em uma unidade de terapia intensiva adulto. Trata-se de uma pesquisa exploratório-descritiva, com abordagem qualitativa, realizada com 14 profissionais de saúde de um hospital público de ensino. Os dados foram coletados entre fevereiro e abril de 2012, através de entrevista semiestruturada e observação não participante e interpretados pela análise de conteúdo. Foram identificadas três categorias temáticas: Assistir o paciente terminal em UTI promovendo o conforto físico; Despreparo da equipe em lidar com o paciente terminal; e Desafios na prática dos cuidados paliativos no ambiente da terapia intensiva. Os entrevistados referiram conhecer parcialmente a proposta dos cuidados paliativos e na prática assistencial observam-se divergências nas condutas terapêuticas da equipe, demonstrando falta de interação e de comunicação entre os profissionais. Faz-se necessário a elaboração de uma política nacional que respalde o cuidado ao paciente crítico terminal, a educação permanente/continuada dos profissionais e a criação de protocolos assistenciais para promoção do conforto do paciente durante a fase final da vida e de sua família.

The scope of this paper was to analyze the perceptions of the multi-professional team on the implementation of palliative care in an adult intensive care unit. An exploratory-descriptive study using a qualitative approach was conducted with 14 health professionals from a public teaching hospital. The information was collected between February and April 2012, by means of semi-structured interviews and non-participatory observation interpreted using content analysis. Three thematic categories were identified: Care for terminal patients in an ICU fostering physical comfort; Lack of preparation of the team in dealing with terminal patients; and Challenges of palliative care practices in the intensive care environment. The interviewed parties reported having some knowledge of the proposal for palliative care though divergences were observed in the therapeutic conduct of the team in the care provided, demonstrating a lack of interaction and communication among the professionals. The drafting of a national policy to promote care for terminally ill patients is necessary, as well as ongoing training of professionals and the creation of care protocols for promoting the comfort of the patients and their families during the end of life phase.

Treatment with midazolam for sleep disturbance of terminally ill patients with cancer in general wards

<b>Background</b>: In terminally ill patients with cancer, sleep disturbance makes worse their quality of life. Midazolam has not ever been used for the treatment of sleep disturbance in general wards of our hospital, used in palliative care unit of other hospital, however. <b>Method</b>: This is a retrospective study based on chart review. Twenty-eight patients who were treated with midazolam for sleep disturbance included in this study. We designed evaluation methods to strictly follow the actual chart descriptions. Efficacy was rated as good, fair, or poor. Safety was defined by the presence or absence of respiratory depression and hypotension. <b>Results</b>: The median administration periods and initial doses were 6 days (range, 1-151) and 5.0 mg/night (1.8-20.0), respectively. Fourteen patients showed good sleep a night after midazolam infusion, four and nine patients showed fair and poor sleep, respectively. No patient demonstrated a respiratory rate of less than 8/min and systolic blood pressure of <60 mmHg at any point during and after midazolam infusion. <b>Conclusion</b>: Intravenous midazolam appeared to be safe for sleep disturbance of terminally ill patients with cancer in general wards. A future improvement administration methods are necessary to treat for sleep disturbance more effectively as well as PCU.

Cuidados Paliativos na Atenção Básica: depoimentos de profissionais da Saúde / Care in Basic Attention: testimonies of Health professionals

INTRODUÇÃO Os Cuidados Paliativos são considerados como uma filosofia do cuidar, cujo escopo é o de proporcionar aos pacientes sem possibilidades terapêuticas de cura e seus familiares uma melhor qualidade de vida, sendo a sua aplicação de suma importância no âmbito da Atenção Básica. OBJETIVOS Este estudo tem os seguintes objetivos: investigar o entendimento de profissionais que atuam na ESF, no que concerne aos Cuidados Paliativos e suas modalidades terapêuticas; identificar, na visão dos profissionais da ESF, a constituição da equipe de Cuidados Paliativos para a Atenção Básica; verificar as possibilidades e limitações de implementação de Cuidados Paliativos na Atenção Básica, a partir do discurso de profissionais da Saúde. METODOLOGIA Trata-se de uma pesquisa exploratória com abordagem qualitativa. O cenário da investigação constituiu-se de unidades de saúde da família pertencentes ao Distrito Sanitário IV, localizadas no município de João Pessoa (PB). Participaram do trabalho trinta profissionais da ESF, sendo dez médicos, dez enfermeiros e dez cirurgiões-dentistas. Na coleta de dados, utilizou-se um formulário contendo questões pertinentes aos objetivos propostos para a pesquisa. A coleta dos dados ocorreu entre julho e setembro de 2011. ANÁLISE DOS DADOS O material empírico foi analisado mediante a técnica de análise de conteúdo, a partir das seguintes fases: pré-análise; exploração do material; tratamento dos resultados. Os dados obtidos por meio dos depoimentos dos participantes da investigação foram agrupados nas seguintes categorias temáticas: Cuidados Paliativos aspectos conceituais e modalidades terapêuticas (com suas respectivas subcategorias: Cuidados Paliativos promoção de qualidade de vida para pacientes sem possibilidades de cura; modalidades terapêuticas em cuidados paliativos); Cuidados Paliativos na Atenção Básica formação da equipe, possibilidades e limitações.

INTRODUCTION - Palliative care are considered as a care philosophy, whose scope is to provide to patients without therapeutic possibilities of cure and their families a better quality of life, being its application of great importance in the context of Primary Care. OBJECTIVES This study has the following objectives: to investigate the understanding of professionals working in FHS, in what concerns to Palliative Care and its therapeutics modalities; to identify, in the view of professionals from FHS, the constitution of Palliative care team for Basic Attention; to verify the possibilities and limitation of implementing Palliative Care in Basic Attention; from the discourse of Health professionals. METHODOLOGY Its about and exploratory research with qualitative approach. The scenario of investigation consisted of family care units belonging to Sanitary District IV, located in the city of João Pessoa (PB). Participated in the work 30 professionals from FHS, being ten doctors, ten nurses and ten dental surgeons. Data collection occurred between July and September 2011. DATA ANALYSIS empirical material was analyzed through content analysis technique, from the following phases: pre-analysis; material exploration; treatment of results. Data obtained by means of testimonies of investigation participants were grouped into the following thematic categories: Palliative Care conceptual aspects and therapeutic modalities (with their respective subcategories: Palliative Care promotion of life quality for patients without possibilities of cure; therapeutic modalities in palliative care); Palliative Care in Basic Attention team formation, possibilities and limitations.

Withholding Futile Interventions from Terminally Ill Cancer Patients

With development of new techniques for medical intervention, there has been a big dilemma for physicians about their decision when to stop treatment. Application of life-sustaining device sometimes results in a prolongation of painful period (dying process) for patients. Regarding the role of physician in the end-of-life decision, there could be two extremes : euthanasia vs. therapeutic tenacity (futility or accanimento terapeutico). Either extreme has its own limitations. One of possible solutions is an appropriate application of withholding and withdrawing interventions. However, several considerations are necessary for this. First, the clinical aspect of decision is whether a certain management is proportionate or non-proportionate for a given situation. If there is a chemotherapy regimen that has an efficacy of 15% partial response rate with side effects in the previous study, is it propotionate or non-proportionate treatment for advanced cancer patients? Other aspects of decision is regarding ethical, economical, and legal issues. One type of circumstances that may prompt claims of futility is the discrepancy between the values or goals of involved parties. Other concerns on futility issues are ① is it easy to break the bad news to dying patients in Korean culture? (communication problems at various levels) ② is social welfare system adequate enough not to interfere with a fair decision? Values on the issues like therapeutic decision and withholding life-sustaining treatments in terminally ill cancer patients are discordant between physicians and family members. To resolve controversies on the role of physicians as well as those of patients and their family members should be considered in the final decision.

Telling to the Diagnosis of Cancer to Terminally Ill Patients

Disclosure of a diagnosis of cancer to patients is a major problem among physicians in Korea. Many questions arise when considering issues involved in telling the diagnosis of cancer beyond the question of whether to tell. But there has been no consensus guideline on how, and in what context, to tell the diagnosis of cancer to the patients. The review of the literature reveals that the attitudes of physicians on the truth telling have been changing from favoring non-disclosure to disclosure over time. The disclosure rate was 81.8% in a Korean survey performed in 1990, while it was 65% in a survey in 1979. The younger the patient's age was, the higher the disclosure rate was. This tendency was same in Korean nurses and patients. The majority of Korean patients wanted their doctors to break the bad news, not only because the patients wanted to obtain detailed information about their conditions but also because they believed their doctors. They also wanted their family to hear the truth first, immediately after the diagnosis had been confirmed. The most important issue in the process of disclosing a diagnosis of cancer to patients is truth. Otherwise, doctors will lose the chance to give help to the patients when they are in real need of doctor's help at the very end of their lives.